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Lookabaugh S, McKenna M, Karelsky S, Davis M, Didas A, Allen P, Faria J. Drug-induced sleep endoscopy findings in surgically-naïve obese vs non-obese children. Int J Pediatr Otorhinolaryngol 2020; 138:110289. [PMID: 32814210 DOI: 10.1016/j.ijporl.2020.110289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine if drug-induced sleep endoscopy (DISE) findings are different in obese versus non-obese pediatric patients with obstructive sleep apnea (OSA) or sleep-disordered breathing (SDB). METHODS Prospective, observational cohort study from June 2017 to June 2018 at a tertiary academic pediatric medical center that included surgically-naïve children ages 2-12 with diagnoses of OSA or sleep-disordered breathing. Subjects with a known diagnosis of craniofacial syndromes, genetic disorders, prior adenoidectomy or tonsillectomy, or chronic tonsillitis as the indication for surgery were excluded. Two groups were assessed for patterns of obstruction based on DISE videos at each anatomic airway level using a previously published DISE scoring system. The groups included obese subjects (BMI ≥ 95th percentile) and non-obese controls (BMI <85th percentile). Each video was graded by two blinded, fellowship-trained Pediatric Otolaryngologists. RESULTS Fifty-one patients were included, 26 non-obese and 25 obese. Based on anatomic airway level, there was no statistically significant difference in airway obstruction at the velum (p = 0.134), adenoid (p = 0.592), lateral pharyngeal walls (p = 0.867), tongue base (p = 0.977), or supraglottis (p = 0.428) between obese and non-obese children. CONCLUSION Our prospective study did not associate severity of obstruction with obesity status based on anatomic airway levels. Further studies are needed to elucidate the etiology of the high rate of persistent obstructive sleep apnea in obese children.
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Affiliation(s)
- Sarah Lookabaugh
- Department of Otolaryngology Head and Neck Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA.
| | - Margo McKenna
- Department of Otolaryngology Head and Neck Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Sveta Karelsky
- Department of Otolaryngology Head and Neck Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael Davis
- Department of Anesthesiology, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Amanda Didas
- Department of Otolaryngology Head and Neck Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Paul Allen
- Department of Otolaryngology Head and Neck Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - John Faria
- Department of Otolaryngology Head and Neck Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY, USA
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Cheong CS, Loke W, Thong MKT, Toh ST, Lee CH. The Emerging Role of Drug-Induced Sleep Endoscopy in the Management of Obstructive Sleep Apnea. Clin Exp Otorhinolaryngol 2020; 14:149-158. [PMID: 33092317 PMCID: PMC8111386 DOI: 10.21053/ceo.2020.01704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/29/2020] [Indexed: 11/22/2022] Open
Abstract
Obstructive sleep apnea is a prevalent sleep disorder characterized by partial or complete obstruction of the upper airway. Continuous positive airway pressure is the first-line therapy for most patients, but adherence is often poor. Alternative treatment options such as mandibular advancement devices, positional therapy, and surgical interventions including upper airway stimulation target different levels and patterns of obstruction with varying degrees of success. Drug-induced sleep endoscopy enables the visualization of upper airway obstruction under conditions mimicking sleep. In the era of precision medicine, this additional information may facilitate better decision-making when prescribing alternative treatment modalities, with the hope of achieving better adherence and/or success rates. This review discusses the current knowledge and evidence on the role of drug-induced sleep endoscopy in the non-positive airway pressure management of obstructive sleep apnea.
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Affiliation(s)
- Crystal Sj Cheong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore
| | - Weiqiang Loke
- Faculty of Dentistry, National University of Singapore, Singapore
| | - Mark Kim Thye Thong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore
| | - Song Tar Toh
- Department of Otolaryngology, Singapore General Hospital, SingHealth Duke-NUS Sleep Centre, Singapore
| | - Chi-Hang Lee
- Department of Cardiology, National University Heart Centre Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cardiovascular Research Institute, National University of Singapore, Singapore
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Op de Beeck S, Dieltjens M, Verbruggen AE, Vroegop AV, Wouters K, Hamans E, Willemen M, Verbraecken J, De Backer WA, Van de Heyning PH, Braem MJ, Vanderveken OM. Phenotypic Labelling Using Drug-Induced Sleep Endoscopy Improves Patient Selection for Mandibular Advancement Device Outcome: A Prospective Study. J Clin Sleep Med 2020; 15:1089-1099. [PMID: 31482830 DOI: 10.5664/jcsm.7796] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVES Mandibular advancement device (MAD) outcome varies between patients. We hypothesized that upper airway collapse sites, patterns, and degrees assessed during baseline drug-induced sleep endoscopy (DISE) affect MAD outcome. METHODS One hundred patients with obstructive sleep apnea (OSA) were included and underwent baseline type 1 polysomnography. MAD was fitted intraorally at fixed 75% maximal protrusion. A total of 72 patients completed 3-month follow-up polysomnography and baseline DISE. Response was defined as apnea-hypopnea index (AHI) reduction ≥ 50%, deterioration as AHI increases during MAD treatment compared to baseline. RESULTS Adjusting for baseline AHI and body mass index, patients with tongue base collapse showed 3.69 higher odds (1.27-10.73; P = .0128) for response. Complete concentric collapse at the level of the palate (5.32 [1.21-23.28]; P = .0234) and complete laterolateral oropharyngeal collapse (6.62 [1.14-38.34]; P = .0330) related to deterioration. Results for tongue base collapse and complete concentric collapse at the level of the palate were confirmed in the moderate to severe OSA subgroup. Applying these results to this selected subgroup increased response rate with 54% and decreased deterioration rate with 53%. These results were confirmed using other response and deterioration definitions. CONCLUSIONS Three baseline DISE phenotypes identified during drug-induced sleep were significantly related to MAD treatment outcome: one beneficial, tongue base collapse, and two adverse, complete concentric collapse at the level of the palate and complete laterolateral oropharyngeal collapse. If confirmed in future prospective studies, these results could guide patient selection for MAD outcome. CLINICAL TRIAL REGISTRATION This prospective clinical trial (PROMAD) was registered on Clinicaltrials.gov with identifier: NCT01532050. CITATION Op de Beeck S, Dieltjens M, Verbruggen AE, Vroegop AV, Wouters K, Hamans E, Willemen M, Verbraecken J, De Backer WA, Van de Heyning PH, Braem MJ, Vanderveken OM. Phenotypic labelling using drug-induced sleep endoscopy improves patient selection for mandibular advancement device outcome: a prospective study. J Clin Sleep Med. 2019;15(8):1089-1099.
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Affiliation(s)
- Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Annelies E Verbruggen
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Anneclaire V Vroegop
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Kristien Wouters
- Clinical Trial Centre (CTC), CRC Antwerp, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Evert Hamans
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium; Department of Pulmonology, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Wilfried A De Backer
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Paul H Van de Heyning
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Marc J Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
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Sebastian A, Cistulli PA, Cohen G, de Chazal P. Automated identification of the predominant site of upper airway collapse in obstructive sleep apnoea patients using snore signal. Physiol Meas 2020; 41:095005. [DOI: 10.1088/1361-6579/abaa33] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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55
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Van de Perck E, Vroegop AV, Op de Beeck S, Dieltjens M, Verbruggen AE, Van de Heyning PH, Braem MJ, Vanderveken OM. Awake endoscopic assessment of the upper airway during tidal breathing: Definition of anatomical features and comparison with drug-induced sleep endoscopy. Clin Otolaryngol 2020; 46:234-242. [PMID: 33002312 DOI: 10.1111/coa.13653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 07/31/2020] [Accepted: 09/20/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Awake nasopharyngoscopy is routinely performed in the assessment of patients who require treatment for sleep-disordered breathing (SDB). However, the applicability and accuracy of Müller's manoeuvre, the main evaluation method for this purpose, are disputable. The current study aimed to introduce an alternative method for awake nasopharyngoscopy in patients with SDB. DESIGN We defined qualitative anatomical features during tidal breathing at the levels of the soft palate, oropharynx, tongue base, epiglottis and hypopharynx, and compared these awake features to the sites and patterns of collapse as observed during drug-induced sleep endoscopy (DISE). SETTING Tertiary care academic centre. PARTICIPANTS Seventy-three patients diagnosed with SDB. MAIN OUTCOME MEASURES The primary outcome measure was the Kendall's tau correlation coefficient (τ) between observations during awake nasopharyngoscopy and DISE. Kappa-statistics (κ) were calculated to assess the agreement on awake endoscopic features with a second observer. RESULTS In contrast to epiglottis shape, the modified Cormack-Lehane scale was significantly associated with epiglottis collapse during DISE (P < .0001; τ = .45). Other upper airway features that were correlated with DISE collapse were the position of the soft palate (P = .007; τ = .29), crowding of the oropharynx (P = .026; τ = .32) and a posteriorly located tongue base (P = .046; τ = .32). Interobserver agreement of endoscopic features during tidal breathing was moderate (0.60 ≤ κ < 0.80). CONCLUSION The current study introduces a comprehensive and reliable assessment method for awake nasopharyngoscopy based on anatomical features that are compatible with DISE collapse patterns.
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Affiliation(s)
- Eli Van de Perck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Anneclaire V Vroegop
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Annelies E Verbruggen
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Paul H Van de Heyning
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc J Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
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56
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Op de Beeck S, Van de Perck E, Vena D, Kazemeini E, Dieltjens M, Willemen M, Wellman A, Verbraecken J, Sands SA, Vanderveken OM. Flow-Identified Site of Collapse During Drug-Induced Sleep Endoscopy: Feasibility and Preliminary Results. Chest 2020; 159:828-832. [PMID: 32941861 PMCID: PMC8438160 DOI: 10.1016/j.chest.2020.09.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 07/31/2020] [Accepted: 09/11/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium.
| | - Eli Van de Perck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Elahe Kazemeini
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Johan Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium; Department of Pulmonology, Antwerp University Hospital, Edegem, Belgium
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium; ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium; Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
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Zhao C, Viana A, Ma Y, Capasso R. Insights into Friedman stage II and III OSA patients through drug-induced sleep endoscopy. J Thorac Dis 2020; 12:3663-3672. [PMID: 32802445 PMCID: PMC7399404 DOI: 10.21037/jtd-20-1471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The Friedman staging is a classic system to predict outcomes of obstructive sleep apnea (OSA) surgery. Increasing stage indicates more severe upper airway (UA) obstruction and worse surgical successful rate. In previous studies, the UA obstruction between stages were usually assessed based on awake examination. Drug-induced sleep endoscopy (DISE) is a new method that can evaluate airway collapse characteristics during sleep. Therefore, we planned to compare Friedman staging and DISE findings and fulfill the knowledge gap on the correlation between awake and sedated UA examination. Methods Retrospective case series study that assessed patients with OSA who underwent DISE. Subjects were classified to stage II and stage III groups based on Friedman staging system. UA collapse characteristics based on velum, oropharynx, tongue base, epiglottis (VOTE) classification, including single/multiple obstruction sites, single/combined upper and lower obstruction levels, collapse degree and patterns in different sites, and surgical results among the groups were analyzed. Results A total of 175 cases were analyzed. No significant differences were found in baseline measurements between groups. Stage III patients (n=102) had a higher proportion (74.5%) with 3 or 4 obstruction sites than stage II (57.5%, n=73). Velum (V) + oropharynx (O) + tongue base (T) was the most common multi-sites combined obstruction pattern with 33% in stage II and 37% in stage III, isolated lower level obstruction was the least with 6% and 4%, respectively. No significant differences were found in obstruction sites and levels. 106 patients underwent surgeries and 33 had post-surgical sleep study, 73.7% and 63.6% response rate were found in stage II and III with no significant difference. Conclusions Upper and lower combined obstruction was the main pattern of collapse in both, Friedman stage II and III patients. Patients with OSA and Friedman stage III had more than 2 sites of obstruction than stage II patients.
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Affiliation(s)
- Chen Zhao
- Department of Otorhinolaryngology, the First Affiliated Hospital of China Medical University, Shenyang, China.,Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Alonço Viana
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University Medical Center, Stanford, California, USA.,Graduate Program of Neurology, Rio de Janeiro State Federal University (UNIRIO), Brazil.,Department of Otorhinolaryngology, Marcílio Dias Naval Hospital, Brazil
| | - Yifei Ma
- Department of Otolaryngology-Head & Neck Surgery, Stanford University Medical Center, Stanford, California, USA
| | - Robson Capasso
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University Medical Center, Stanford, California, USA
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Whyte A, Gibson D. Imaging of sleep-disordered breathing in adults. Clin Radiol 2020; 75:960.e1-960.e16. [PMID: 32620255 DOI: 10.1016/j.crad.2020.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/15/2020] [Indexed: 10/24/2022]
Abstract
Sleep-disordered breathing (SDB) is a term that includes several chronic conditions in which partial or complete cessation of breathing occurs multiple times throughout the night. Central sleep apnoea (CSA) is uncommon and defined by the episodic cessation of airflow without respiratory effort. Lesions involving the respiratory centre in the brainstem or the origin of the phrenic nerve from the mid-cervical cord are the commonest structural causes of CSA; magnetic resonance imaging (MRI) will demonstrate the lesion and frequently suggest the likely aetiology. In contrast, obstructive sleep apnoea (OSA) is defined as upper airway obstruction despite ongoing respiratory effort. Repetitive episodes of narrowing or closure of the upper airway are the predominant cause leading to snoring and OSA, respectively. OSA affects 33-40% of the adult population and is associated with multiple adverse health consequences, including a significantly increased risk of serious morbidity and mortality. The incidence is increasing proportionally to the worldwide rise in obesity. Imaging, performed primarily without the involvement of radiologists, has been integral to understanding the anatomical basis of SDB and especially OSA. This article will review the pathophysiology, imaging findings, and sequelae of these common conditions. The role of imaging both in suggesting the incidental diagnoses of SDB and in the investigation of these conditions when the diagnosis is suspected or has been established are also discussed.
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Affiliation(s)
- A Whyte
- Perth Radiological Clinic, Subiaco, WA 6008, Australia; Departments of Surgery and Dentistry, University of Western Australia, Nedlands, WA 6009, Australia; Departments of Medicine and Radiology, University of Melbourne, Carlton, Victoria 3000, Australia.
| | - D Gibson
- Departments of Surgery and Dentistry, University of Western Australia, Nedlands, WA 6009, Australia; Imaging Department, Fiona Stanley Hospital, Murdoch, WA 6150, Australia; Department of Medicine, Curtin Medical School, Bentley, WA 6102, Australia
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Liu SYC, Riley RW, Yu MS. Surgical Algorithm for Obstructive Sleep Apnea: An Update. Clin Exp Otorhinolaryngol 2020; 13:215-224. [PMID: 32631040 PMCID: PMC7435437 DOI: 10.21053/ceo.2020.01053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 06/29/2020] [Indexed: 02/04/2023] Open
Abstract
Sleep surgery is part of a continuum of care for obstructive sleep apnea (OSA) that involves medical, pharmacologic, and behavioral therapy. Upper airway surgery for OSA can significantly improve stability by way of modulating the critical negative closing pressure. This is the same mechanism of action as positive airway pressure or oral appliance therapy. The updated surgical algorithm in this review adds precision in three areas: patient selection, identification of previously unaddressed anatomic phenotypes with associated treatment modality, and improved techniques of previously established procedures. While the original Riley and Powell phase 1 and 2 approach to sleep surgery has focused on individual surgical success rate, this algorithm strives for an overall treatment success with multi-modal and patient-centric treatments.
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Affiliation(s)
- Stanley Yung-Chuan Liu
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford Hospital and Clinics, Stanford, CA, USA
| | - Robert Wayne Riley
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford Hospital and Clinics, Stanford, CA, USA
| | - Myeong Sang Yu
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford Hospital and Clinics, Stanford, CA, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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60
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Wong SJ, Luitje ME, Karelsky S. Patterns of Obstruction on DISE in Adults With Obstructive Sleep Apnea Change With BMI. Laryngoscope 2020; 131:224-229. [PMID: 32511760 DOI: 10.1002/lary.28777] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/24/2020] [Accepted: 05/09/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVES We describe drug-induced sleep endoscopy (DISE) obstruction patterns in adults with obstructive sleep apnea (OSA) based on body mass index (BMI). We also evaluate subgroups of patients with clinically significant obstruction patterns at the velopharynx and oropharynx. STUDY DESIGN Retrospective chart review. METHODS Single-institution, retrospective chart review of adults with OSA who underwent DISE with dexmedetomidine sedation from 2016 to 2018. Endoscopic findings were graded using VOTE (Velum, Oropharynx, Tongue base, Epiglottis) classification. Oropharyngeal obstruction was additionally graded with the modifier T when due to palatine tonsil tissue. Findings in patients who had BMI < 25, 25 ≤ BMI < 30, and BMI ≥ 30 were compared. RESULTS One hundred and eleven patients (1 underweight, 23 normal weight, 56 overweight, and 31 obese) were reviewed. Patients with lower BMI were more likely to have more severe obstruction at the level of the tongue base (χ2 = 11.52, P = .021) and epiglottis (χ 2 = 10.56, P = .032). Conversely, patients with higher BMI were more likely to have complete concentric (grade 2C) velum obstruction (χ 2 = 16.04, P < .001) and more severe oropharyngeal obstruction (χ 2 = 9.65, P = .046). Patients with grade 2 oropharyngeal obstruction without tonsil obstruction had more severe concurrent velum obstruction compared to subjects with grade 2 T oropharyngeal obstruction (P = .009). CONCLUSION In adults with OSA, BMI categories have significantly distinct obstruction patterns at all airway levels on DISE, and there appear to be distinct subgroups associated with certain velum and oropharynx collapse patterns. These findings may have important implications for positive airway pressure-alternative treatment. LEVEL OF EVIDENCE 3 Laryngoscope, 131:224-229, 2021.
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Affiliation(s)
- Stephanie J Wong
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Martha E Luitje
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York, U.S.A
| | - Sveta Karelsky
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York, U.S.A
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Hsu YB, Lan MY, Huang YC, Kao MC, Lan MC. Association Between Breathing Route, Oxygen Desaturation, and Upper Airway Morphology. Laryngoscope 2020; 131:E659-E664. [PMID: 32473063 DOI: 10.1002/lary.28774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/26/2020] [Accepted: 05/09/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES/HYPOTHESIS This study aimed to assess the role of capnography in objectively evaluating breathing routes during drug-induced sleep endoscopy (DISE) and further elucidate the relationship between breathing route, obstructive sleep apnea (OSA) severity, and DISE findings. STUDY DESIGN Prospective observational study. METHODS Nighty-five patients with established OSA were recruited for this study from May 2017 to May 2019. DISE was performed in the operating room. Sedation was maintained with propofol using a target-controlled infusion system and the depth of sedation was monitored based on the bispectral index. The breathing routes, which included oral breathing, oronasal breathing, and nasal breathing, were detected using capnography. DISE findings were recorded using the VOTE (velum, oropharynx, base of tongue, and epiglottis) classification. RESULTS Patients with mouth breathing were associated with increased OSA severity, worse oximetric variables, and higher body mass index in comparison with those with other breathing routes. Mouth breathing was associated with a higher degree and higher prevalence of lateral pharyngeal wall collapse and tongue base collapse during DISE. CONCLUSIONS Mouth breathing was significantly associated with worse oxygen desaturation and increased degree of upper airway collapse. Therefore, patients with mouth breathing during propofol-based intravenous anesthesia should be carefully monitored. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E659-E664, 2021.
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Affiliation(s)
- Yen-Bin Hsu
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ming-Ying Lan
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yun-Chen Huang
- Department of Otolaryngology-Head and Neck Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ming-Chang Kao
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Ming-Chin Lan
- Department of Otolaryngology-Head and Neck Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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Ordones AB, Grad GF, Cahali MB, Lorenzi-Filho G, Sennes LU, Genta PR. Comparison of upper airway obstruction during zolpidem-induced sleep and propofol-induced sleep in patients with obstructive sleep apnea: a pilot study. J Clin Sleep Med 2020; 16:725-732. [PMID: 32029070 DOI: 10.5664/jcsm.8334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Drug-induced sleep endoscopy (DISE) using propofol is commonly used to identify the pharyngeal structure involved in collapse among patients with obstructive sleep apnea. DISE has never been compared with zolpidem-induced sleep endoscopy. We hypothesized that propofol at recommended sedation levels does not influence upper airway collapsibility nor the frequency of multilevel pharyngeal collapse as compared with zolpidem-induced sleep. METHODS Twenty-one patients with obstructive sleep apnea underwent polysomnography and sleep endoscopy during zolpidem-induced sleep and during DISE with propofol. A propofol target-controlled infusion was titrated to achieve a bispectral index between 50 and 70. Airway collapsibility was estimated and compared in both conditions by peak inspiratory flow and the magnitude of negative effort dependence. Respiratory drive was estimated by the difference between end-expiratory and peak-negative inspiratory pharyngeal pressure (driving pressure). Site and configuration of pharyngeal collapse during zolpidem-induced sleep and DISE with propofol were compared. RESULTS The frequency of multilevel collapse during zolpidem-induced sleep was similar to that observed during DISE with propofol (72% vs 86%, respectively; difference: 14%; 95% confidence interval: -12% to 40%; P = .453). The endoscopic classification of pharyngeal collapse during both conditions were similar. Peak inspiratory flow, respiratory drive (effect size: 0.05 and 0.03, respectively), and negative effort dependence (difference: -6%; 95% confidence interval: -16% to 4%) were also similar in both procedures. CONCLUSIONS In this pilot study, recommended propofol doses did not significantly increase multilevel pharyngeal collapse or affect upper airway collapsibility and respiratory drive as compared with zolpidem-induced sleep. CLINICAL TRIAL REGISTRATION Registry: clinicaltrials.gov; Name: Natural and Drug Sleep Endoscopy; URL: https://clinicaltrials.gov/ct2/show/study/NCT03004014; Identifier: NCT03004014.
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Affiliation(s)
| | - Gustavo Freitas Grad
- Pulmonary Division, Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | | | - Geraldo Lorenzi-Filho
- Pulmonary Division, Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
| | | | - Pedro Rodrigues Genta
- Pulmonary Division, Heart Institute (InCor), Universidade de São Paulo, São Paulo, Brazil
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Chaudhry U, Cohen JR, Al-Samawi Y. Use of cone beam computed tomography imaging for airway measurement to predict obstructive sleep apnea. Cranio 2020; 40:418-424. [PMID: 32396453 DOI: 10.1080/08869634.2020.1765602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: This retrospective chart review examined whether airway parameters were correlated with scores on the STOP-Bang questionnaireMethods: Minimal upper airway area, upper airway volume, minimal retropalatal area, retropalatal volume, minimal retroglossal area, and retroglossal volume were calculated from cone beam computed tomography (CBCT) images. Patients were grouped based on their STOP-Bang scores (<3 or ≥3) for obstructive sleep apnea (OSA), and airway parameters were compared across the 2 groups.Results: Thirty-one (43%) of 72 patients with a minimal upper airway area of <110 mm2 had STOP-Bang scores of ≥3. Most patients (90%) with STOP-Bang scores of ≥3 had minimal retropalatal areas of <110 mm2. Differences were found between groups for minimal upper airway area (P=.03), upper airway volume (P=.04), and minimal retropalatal area (P=.001).Discussion: To assess OSA risk, dentists should compare CBCT images with STOP-Bang scores.
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Affiliation(s)
- Usman Chaudhry
- Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, AZ, USA
| | - Joseph R Cohen
- Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, AZ, USA
| | - Yazan Al-Samawi
- Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, AZ, USA
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Mulholland GB, Dedhia RC. Success of Hypoglossal Nerve Stimulation Using Mandibular Advancement During Sleep Endoscopy. Laryngoscope 2020; 130:2917-2921. [PMID: 32108345 DOI: 10.1002/lary.28589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/24/2020] [Accepted: 02/04/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Hypoglossal nerve stimulation (HGNS) effectively treats obstructive sleep apnea in select patients. Drug-induced sleep endoscopy (DISE) is required for HGNS candidacy. Data suggest that mandibular advancement (MA) devices and HGNS share similar target populations. We aimed to test the association between MA's effect on the velum and lateral walls during DISE in relation to the improvement in the apnea-hypopnea index (AHI) with HGNS. STUDY DESIGN Prospective case series METHODS: All patients completed preoperative polysomnography or home sleep study, DISE with MA prior to HGNS implantation, and full-night efficacy sleep tests. Adult patients with body mass index (BMI) ≤ 35 and AHI ≥ 15 were included. Two independent reviewers scored DISE videos. RESULTS Forty-six patients were included from October 2015 to January 2019. Mean BMI (standard deviation) was 28.5 (3.7) kg/m2 . Patients with a reduced airway response to MA had greater AHI improvement than patients with a robust response (21.7, 95% confidence interval [CI]: 14.4 to 29.0 vs. 4.9, 95% CI: -8.9 to 18.6; P = .03). Patients with complete baseline collapse at the velum and lateral walls (n = 11) had less response compared to those with partial collapse (n = 35) (AHI reduction of 4.4 [95% CI: -8.6 to 17.4] vs. 22.3 [95% CI: 15.1 to 29.6; P = .02]). CONCLUSIONS Patients having significant airway improvement in the upper pharynx with MA during DISE appear less likely to succeed with HGNS. This phenomenon might be secondary to the worsened baseline obstruction of the upper pharynx in such patients. LEVEL OF EVIDENCE 4 Laryngoscope, 2020.
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Affiliation(s)
- Graeme B Mulholland
- Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Raj C Dedhia
- Division of Sleep Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A.,CPAP Alternatives Clinic, Penn Sleep Center, Penn Medicine, Philadelphia, Pennsylvania, U.S.A
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65
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Lin HY, Chang CJ, Chiang CC, Su PL, Lin CY, Hung CH. Effects of a comprehensive physical therapy on moderate and severe obstructive sleep apnea- a preliminary randomized controlled trial. J Formos Med Assoc 2020; 119:1781-1790. [PMID: 32037263 DOI: 10.1016/j.jfma.2020.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/18/2019] [Accepted: 01/19/2020] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Critically compromised by upper airway anatomical impaired properties, obstructive sleep apnea (OSA) can be categorized into different phenotypic traits, mainly including oropharyngeal muscle dysfunction. The upper airway muscle strength training was targeted on oropharyngeal muscle dysfunction by re-educating the oropharyngeal muscles to maintain the upper airway patency. OSA was characterized with multilevel collapsibility of the upper airway; however, the programs are still inconsistent and the effects are unknown. Therefore, the purpose of this study was to investigate the effects of a comprehensive physical therapy on OSA. METHODS Fifteen subjects with newly diagnosed moderate or severe OSA (AHI ≥ 15) were randomized into intervention and control groups. The intervention group underwent a 12-week-intervention of hospital based physical therapy, while the control group was kept on waiting for 12 weeks. Polysomnography (PSG) data, oropharyngeal and respiratory muscle performance were measured before and after intervention. RESULTS In intervention group (n = 8), AHI was significantly improved (from 46.96 ± 19.45 to 32.78 ± 10.78 events/h, p = 0.017); in control group (n = 7), AHI was significantly increased (from 35.77 ± 17.49 to 42.96 ± 17.32 events/h, p = 0.043). While the control group remained no change between pre- and post- intervention, the intervention group demonstrated that other PSG outcomes significantly improved, including arousal index (46.04 ± 18.9 versus 32.98 ± 8.35/h), mean SpO2 (92.88 ± 2.1 versus 94.13 ± 1.46%), and oxygen desaturation index (ODI) (31.13 ± 19.48 versus 20.57 ± 7.83/h). CONCLUSION This comprehensive physical therapy can be prescribed for the significant clinical improvement on sleep apnea for the patients with moderate and severe OSA.
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Affiliation(s)
- Hsin-Yu Lin
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Taiwan
| | - Chih-Ju Chang
- Physical Therapy Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan
| | - Chan-Chi Chiang
- Department of Physical Therapy, Shu-Zen Junior College of Medicine and Management, Taiwan
| | - Po-Lan Su
- Department of Internal Medicine, Division of Pulmonary, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan; Sleep Medicine Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan
| | - Cheng-Yu Lin
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan; Department of Environmental and Occupational Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan; Sleep Medicine Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan
| | - Ching-Hsia Hung
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Taiwan; Department of Physical Therapy, College of Medicine, National Cheng Kung University, Taiwan.
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67
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Oh H, Kim HG, Pyo S, Ji JY, Woo H, Kim M, Kim DY, Rhee CS, Kim HJ. The clinical efficacy of relocation pharyngoplasty to improve retropalatal circumferential narrowing in obstructive sleep apnea patients. Sci Rep 2020; 10:2101. [PMID: 32034229 PMCID: PMC7005705 DOI: 10.1038/s41598-020-58920-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/17/2020] [Indexed: 11/16/2022] Open
Abstract
Lateral pharyngeal wall appears to be a critical culprit of obstructive sleep apnea (OSA) subjects and relocation pharyngoplasty has been expected to be a promising surgical option to correct retropalatal circumferential narrowing in OSA patients. The purpose of our study is to evaluate the therapeutic outcomes of relocation pharyngoplasty and its clinical effectiveness in OSA patients with retropalatal circumferential narrowing. We performed relocation pharyngoplasty combined with nasal surgery in 133 OSA patients with the following characteristics: apnea-hypopnea index (AHI) over 10, retropalatal circumferential narrowing greater than grade I when awake, and redundant soft tissue around the lateral pharyngeal wall. The analysis of surgical success rate was performed with the data of 68 subjects who underwent pre and postoperative polysomnography. The objective success rate of relocation pharyngoplasty was 52.9%, and significant reduction of mean AHI with improvement of lowest SpO2 was seen in 69% of patients 3 months after the surgery. The median AHI was decreased from preoperative 37.3 to postoperative 21.4. Median lowest SpO2 changed from 78.4 to 84.1%. Total sleep time, daytime sleepiness, and visual analogue scale for snoring showed improvement as well. Postoperative complications including pain or bleeding were minimal in 133 subjects and a few patients complained of subtle taste loss. Our data demonstrate that relocation pharyngoplasty can be a favorable surgical option fighting against retropalatal circumferential narrowing.
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Affiliation(s)
- Heonjeong Oh
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyung Gu Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Suyeon Pyo
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeong-Yeon Ji
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyunjun Woo
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Minju Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong-Young Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chae-Seo Rhee
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyun Jik Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea.
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68
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Vroegop AV, Vanderveken OM, Verbraecken JA. Drug-Induced Sleep Endoscopy: Evaluation of a Selection Tool for Treatment Modalities for Obstructive Sleep Apnea. Respiration 2020; 99:451-457. [PMID: 32036366 DOI: 10.1159/000505584] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 12/20/2019] [Indexed: 11/19/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a very common disorder with important day and nighttime symptoms and long-term effects on health. Different treatment modalities such as positive airway pressure (PAP), oral appliance therapy using custom-made, titratable mandibular advancement devices (MAD), different types of surgery and positional therapy have been introduced over the years, with patient preference and adherence to therapy being key elements in improving treatment outcomes. Several patient selection tools to improve treatment outcomes have been introduced and evaluated over the years. Drug-induced sleep endoscopy (DISE) is a procedure that provides real-time upper airway evaluation of the sites of flutter and upper airway collapse. This review focuses on the indications and contraindications for DISE, methods of sedation and evaluation, add-on maneuvers, and the results on patient selection and treatment outcomes. A PICO approach was used to clarify the aims of this review. DISE has the advantage of being easily accessible in most ENT practices and being 3-dimensional, dynamic, site specific, safe and it is valuable in selecting patients for upper airway surgery and oral appliance therapy. There is a strong interest for further standardization and exploration of the predictive value of this evolving technique.
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Affiliation(s)
- Anneclaire V Vroegop
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium, .,Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium, .,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium,
| | - Olivier M Vanderveken
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan A Verbraecken
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium.,Department of Pulmonary Medicine, Antwerp University Hospital, Edegem, Belgium
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69
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Baptista PM, Costantino A, Moffa A, Rinaldi V, Casale M. Hypoglossal Nerve Stimulation in the Treatment of Obstructive Sleep Apnea: Patient Selection and New Perspectives. Nat Sci Sleep 2020; 12:151-159. [PMID: 32104122 PMCID: PMC7026121 DOI: 10.2147/nss.s221542] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/01/2020] [Indexed: 12/22/2022] Open
Abstract
Hypoglossal nerve stimulation (HNS) is an increasingly widespread OSA treatment. It is a non-anatomical modifying surgery able to achieve an adequate objective and subjective result with a reasonable complication rate. HNS exploits the neurostimulation to reduce upper airway collapsibility providing a multilevel upper airway improvement within a single procedure. Proper patient selection has a fundamental role in determining an adequate long-term clinical outcome. All patient candidates for HNS undergo a standard comprehensive sleep medicine assessment and upper airway surgical examination. Several features should be assessed preoperatively in order to predict patients' response to HNS treatment. In particular, the assessment of OSA severity, BMI > 32 Kg/m2, collapse pattern during drug-induced sleep endoscopy (DISE), and many other parameters, is central for a good patient selection and customization of OSA treatment. HNS is indeed one of the most promising tools in the widespread context of personalized sleep medicine. HNS is an adjustable medical device that could be titrated in order to improve HNS effectiveness, maintaining patient comfort. Moreover, HNS provides the opportunity for patients to play an active role in their own care, with a potential improvement in therapy adherence and efficacy. This review summarizes the current evidence in patient selection for HNS, highlighting the reasons behind the optimistic future of this OSA treatment in the context of personalized medicine.
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Affiliation(s)
- Peter M Baptista
- Department of ORL, Clínica Universidad de Navarra, Pamplona, Spain
| | - Andrea Costantino
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center-IRCCS, Milan, Italy
| | - Antonio Moffa
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy.,Department of Otolaryngology, University of Foggia, Foggia, Italy
| | - Vittorio Rinaldi
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy
| | - Manuele Casale
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy
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Zhao C, Viana A, Ma Y, Capasso R. High Tongue Position is a Risk Factor for Upper Airway Concentric Collapse in Obstructive Sleep Apnea: Observation Through Sleep Endoscopy. Nat Sci Sleep 2020; 12:767-774. [PMID: 33117012 PMCID: PMC7585274 DOI: 10.2147/nss.s273129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/14/2020] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Identification of upper airway (UA) obstruction based on pharyngeal factors is important for obstructive sleep apnea (OSA) evaluation. This study is to assess the association between UA collapse characteristics and Friedman tongue position (FTP) in patients with OSA through drug-induced sleep endoscopy (DISE). PATIENTS AND METHODS Retrospective study in individuals with OSA who were intolerant to continuous positive airway pressure (CPAP) treatment, submitted to DISE between June 1, 2013, and July 31, 2017. All subjects were classified as having an FTP grade of I to IV, and the velum, oropharynx, tongue base, epiglottis (VOTE) classification was used to analyze the DISE findings. UA collapse characteristics by DISE and FTP grading were compared between groups. The associations between specific DISE findings and FTP were analyzed. RESULTS In total, 205 patients were assessed. A positive and significant correlation was identified between the presence of retropalatal complete concentric collapse (CCC) and FTP grade, according to the following distributions: I, 17.4%; II, 22.9%; III, 33.7%; and IV, 48.7% (P = 0.014). A logistic regression model revealed that CCC was associated with FTP grade IV. After adjusting for age, sex, body mass index (BMI), and tonsil size (TS), the grade IV individuals had a 4.4-fold higher risk of having CCC than grade I individuals (P = 0.026). Multiple collapse sites and palatopharyngeal or combined (palatopharyngeal and hypopharyngeal) collapse were more prevalent in grade IV individuals. CONCLUSION OSA patients intolerant to CPAP have a strong positive correlation between the FTP grade and presence of retropalatal CCC. FTP grade IV is an independent risk factor for velum-CCC, controlling for sex, age, BMI, and TS grade.
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Affiliation(s)
- Chen Zhao
- Department of Otorhinolaryngology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China.,Division of Sleep Surgery, Department of Otolaryngology- Head & Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Alonço Viana
- Division of Sleep Surgery, Department of Otolaryngology- Head & Neck Surgery, Stanford University Medical Center, Stanford, CA, USA.,Graduate Program of Neurology, Rio de Janeiro State Federal University (UNIRIO), Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Marcílio Dias Naval Hospital, Rio de Janeiro, Brazil
| | - Yifei Ma
- Department of Otolaryngology- Head & Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Robson Capasso
- Division of Sleep Surgery, Department of Otolaryngology- Head & Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
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Lin HY, Su PL, Lin CY, Hung CH. Models of anatomically based oropharyngeal rehabilitation with a multilevel approach for patients with obstructive sleep apnea: a meta-synthesis and meta-analysis. Sleep Breath 2019; 24:1279-1291. [PMID: 31836993 DOI: 10.1007/s11325-019-01971-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/17/2019] [Accepted: 11/02/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) is a sleep-related breathing disorder associated with dysfunction of oropharyngeal muscles to maintain upper airway patency during sleep. Oropharyngeal rehabilitation (OPR) was developed to restore, reconstruct, and reeducate oropharyngeal muscle function, but current protocols and effectiveness of OPR have been inconsistent. The purpose of this study was to review (1) indications of OPR, (2) protocols of OPR, and (3) effectiveness of OPR. METHODS We searched MEDLINE, EMBASE, and the Cochrane Library and then conducted both meta-synthesis and meta-analysis according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). RESULTS A total of eight studies with 203 patients were included. By means of meta-synthesis, the patients with middle age, BMI < 40 kg/m2, mild-to-moderate OSA, and non-severe upper airway anatomical abnormality were found to benefit from OPR. The protocol of OPR was summarized to be an anatomically based, multilevel approach, including the retropalatal, retroglossal, hypopharyngeal, TMJ, and facial levels. By using meta-analysis, overall outcomes were presented as apnea hypopnea index (AHI) with significant improvement from 25.2 ± 7.8/h to 16.1 ± 6.6/h (mean difference [MD] - 9.8 [95% CI - 11.0 to - 8.6], p < 0.0001); the lowest oxygen saturation (LSAT) improved from 80.2 ± 4.7 to 83.8 ± 2.9% (MD 3.0% [95% CI 2.0 to 4.0], p < 0.0001); Epworth sleepiness scale (ESS) improved from 11.8 ± 1.9 to 6.3 ± 1.6 (MD - 5.9 [95% CI - 7.5 to - 4.2], p < 0.001), neck circumference (NC) from 35.2 ± 1.1 to 34.7 ± 0.9 cm (MD - 0.6 [95% CI - 0.9 to - 0.2], p = 0.002), BMI from 24.8 ± 3.7 to 24.8 ± 4.1 kg/m2 (MD - 0.0; 95% CI - 0.5 to 0.5, p = 0.95). All outcomes except BMI demonstrated significant improvement from OPR. CONCLUSIONS Meta-analysis of previous OPR reports shows an improvement in AHI of 39%, compared with the usual surgical definition of success at 50%. Only mild and moderate cases of OSA were referred for OPR in the prior studies. In order to improve outcomes with OPR, a comprehensive approach to rehabilitation should be emphasized.
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Affiliation(s)
- Hsin-Yu Lin
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, No. 1 Ta-Hsueh Road, East District, Tainan City, 701, Taiwan
| | - Po-Lan Su
- Department of Internal Medicine, Division of Pulmonary, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, North District, Tainan City, 704, Taiwan
| | - Cheng-Yu Lin
- Department of Otolaryngology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, North District, Tainan City, 704, Taiwan.,Department of Environmental and Occupational Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, North District, Tainan City, 704, Taiwan.,Sleep Medicine Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, North District, Tainan City, 704, Taiwan
| | - Ching-Hsia Hung
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, No. 1 Ta-Hsueh Road, East District, Tainan City, 701, Taiwan. .,Department of Physical Therapy, College of Medicine, National Cheng Kung University, No. 1 Ta-Hsueh Road, East District, Tainan City, 701, Taiwan.
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Yui MS, Tominaga Q, Lopes BCP, Eckeli AL, Rabelo FAW, Küpper DS, Valera FCP. Nasal vs. oronasal mask during PAP treatment: a comparative DISE study. Sleep Breath 2019; 24:1129-1136. [PMID: 31797217 DOI: 10.1007/s11325-019-01976-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/02/2019] [Accepted: 11/12/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE The present study evaluated the upper airway pattern of obstruction in individuals undergoing drug-induced sleep endoscopy (DISE) exam with positive airway pressure (PAP), and compared this effect through a nasal or oronasal mask. METHODS Prospective study. Patients requiring PAP due to obstructive sleep apnea (OSA) were evaluated through DISE at three different moments: (1) a baseline condition (without PAP); (2) PAP treatment with a nasal mask; and (3) PAP with an oronasal mask at the same pressure. The conditions were compared intra-individually, following VOTE classification. A TOTAL VOTE score (the sum of VOTE scores observed for each anatomical site) was also applied to compare intra-individual results. RESULTS Thirteen patients were enrolled in the study. All patients presented multi-level pharyngeal obstruction at baseline condition. In six patients, the pattern of obstruction differed according to the mask. Nasal mask significantly decreased the obstruction score when compared with baseline condition both in velum (P value < 0.05) and oropharynx regions (P value < 0.005). TOTAL VOTE score was also significantly lower during nasal mask evaluation when compared with basal condition (P value < 0.005). Remarkably, oronasal mask with the same pressure was not as effective as nasal masks. Obstruction levels observed at the tongue base or epiglottis levels were more resistant to PAP treatment. CONCLUSIONS Collapse in velum and oropharyngeal sites is more compliant to PAP than obstruction at lower levels of the pharynx, either with nasal or oronasal masks. Nasal mask is superior to prevent pharyngeal collapse than oronasal devices under the same pressure.
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Affiliation(s)
- Mariane S Yui
- ENT Division, Clinics Hospital, Medical School of Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900-12o andar, Ribeirão Preto-São Paulo, CEP 14049-900, Brazil
| | - Quedayr Tominaga
- ENT Division, Clinics Hospital, Medical School of Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900-12o andar, Ribeirão Preto-São Paulo, CEP 14049-900, Brazil
| | - Bruno C P Lopes
- Anesthesiology Division, Clinics Hospital, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Alan L Eckeli
- Neurosciences Department, Clinics Hospital, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Daniel S Küpper
- ENT Division, Clinics Hospital, Medical School of Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900-12o andar, Ribeirão Preto-São Paulo, CEP 14049-900, Brazil
| | - Fabiana C P Valera
- ENT Division, Clinics Hospital, Medical School of Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900-12o andar, Ribeirão Preto-São Paulo, CEP 14049-900, Brazil.
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Transoral Robotic Surgery for Obstructive Sleep Apnea. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00253-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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74
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Bartier S, Blumen M, Chabolle F. Is image interpretation in drug-induced sleep endoscopy that reliable? Sleep Breath 2019; 24:677-685. [DOI: 10.1007/s11325-019-01958-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 06/12/2019] [Accepted: 10/02/2019] [Indexed: 11/29/2022]
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Dieltjens M, Braem MJ, Op de Beeck S, Vroegop AVMT, Kazemeini E, Van de Perck E, Beyers J, Kastoer C, Wouters K, Willemen M, Verbraecken JA, Vanderveken OM. Remotely controlled mandibular positioning of oral appliance therapy during polysomnography and drug-induced sleep endoscopy compared with conventional subjective titration in patients with obstructive sleep apnea: protocol for a randomized crossover trial. Trials 2019; 20:615. [PMID: 31665059 PMCID: PMC6820920 DOI: 10.1186/s13063-019-3698-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 09/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The amount of mandibular protrusion is a key factor in optimizing the efficacy of mandibular advancement device (MAD) therapy in an individual patient diagnosed with obstructive sleep apnea. This process is called titration and is generally based on resolution of subjective symptoms like snoring and/or daytime sleepiness as a function of protrusion. An objective approach uses a remotely controlled mandibular positioner (RCMP) during a full-night polysomnography (PSG), in analogy with continuous positive airway pressure (CPAP) titration. More recently, the feasibility of RCMP use during drug-induced sleep endoscopy (DISE) titration was reported. METHODS This randomized crossover trial will compare DISE-assisted titration to PSG-guided titration, as well as with the conventional subjective titration method. The primary outcome is the actual mandibular protrusive position found to be the most optimal for each tested titration procedure. Furthermore, the therapeutic efficacy will be compared among the different titration modalities using level 1 sleep studies. DISCUSSION Currently, the optimal titration of MAD therapy is most often based on 'trial and error'. The conventional method relies on subjective improvement in symptoms, although this may not provide the most accurate indicator for efficient titration. Therefore, relying on objective criteria in the titration process should be advantageous. In analogy with CPAP, titration of the most optimal mandibular protrusion could be performed using RCMP during an overnight titration PSG. Recently, it was shown that titration under direct visualization of upper airway patency and collapsibility is feasible using the RCMP during DISE. However, no clinical results for such a procedure are as yet available. This study is the first to compare the most optimal mandibular protrusive position according to three titration procedures, as well as to compare the therapeutic efficacy of these titration methods. TRIAL REGISTRATION ClinicalTrials.gov, NCT03716648 . Registered on 23 October 2018.
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Affiliation(s)
- Marijke Dieltjens
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium. .,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium. .,Department of Special Dentistry Care, Antwerp University Hospital, Edegem, Antwerp, Belgium.
| | - Marc J Braem
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium.,Department of Special Dentistry Care, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Sara Op de Beeck
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Anneclaire V M T Vroegop
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium
| | - Elahe Kazemeini
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium
| | - Eli Van de Perck
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium
| | - Jolien Beyers
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium
| | - Chloé Kastoer
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium
| | - Kristien Wouters
- Clinical Trial Center, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Johan A Verbraecken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Antwerp, Belgium.,Department of Pulmonology, Antwerp University Hospital, Edegem, Antwerp, Belgium.,Laboratory of Experimental Medicine and Pediatrics (LEMP), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium
| | - Olivier M Vanderveken
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium.,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium.,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Antwerp, Belgium
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Lan WC, Chang WD, Tsai MH, Tsou YA. Trans-oral robotic surgery versus coblation tongue base reduction for obstructive sleep apnea syndrome. PeerJ 2019; 7:e7812. [PMID: 31592178 PMCID: PMC6778434 DOI: 10.7717/peerj.7812] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 09/01/2019] [Indexed: 01/04/2023] Open
Abstract
Objectives To compare the efficacy of trans-oral robotic surgery (TORS) with that of coblation assisted tongue base reduction surgery in patients with obstructive sleep apnea syndrome (OSAS). Subjects and Methods The medical charts were retrospectively reviewed for all OSAS patients admitted to one institution for surgical intervention between 2012 and 2017. We analyzed 33 cases; 16 patients received TORS and 17 received coblation surgery for tongue base reduction. Both groups received concomitant uvulopalatoplasty. Surgical outcomes were evaluated by comparing the initial polysomnography (PSG) parameters with the follow-up PSG data (at least 3 months after the surgery). Epworth sleepiness scale (ESS) and complications were also compared between the 2 groups. Results The success rate (≥50% reduction of pre-operative AHI and post-operative AHI <20) in the TORS group and coblation group were 50% and 58%, respectively, and there was no significant difference (p = .611). The AHI (mean ± SD) reduction in the TORS and coblation groups were 24.9 ± 26.5 events/h and 19.4 ± 24.8 events/h, respectively; the between-group difference was not significant (p = .631). ESS improvement did not differ significantly between the TORS and coblation groups (3.8 ± 6.6 and 3.1 ± 9.2, respectively, p = .873). The rates of minor complication were higher in the TORS group (50%) than that of the coblation group (35.3%) without statistical significance (p = .393). Conclusion TORS achieved comparable surgical outcomes compared to coblation assisted tongue base reduction surgery in OSAS patients. Multilevel surgery using either TORS or coblation tongue base reduction combined with uvulopalatoplasty is an effective approach for the management of OSAS.
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Affiliation(s)
- Wei-Che Lan
- Department of Otolaryngology Head and Neck Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Wen-Dien Chang
- Department of Sport Performance, National Taiwan University of Sport, Taichung, Taiwan
| | - Ming-Hsui Tsai
- Department of Otolaryngology Head and Neck Surgery, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan.,Department of Audiology and Speech-Language Pathology, Asia University, Taichung, Taiwan
| | - Yung-An Tsou
- Department of Otolaryngology Head and Neck Surgery, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan.,Department of Audiology and Speech-Language Pathology, Asia University, Taichung, Taiwan
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Vicini C, Colabianchi V, Giorgio Marrano G, Barbanti F, Spedicato GA, Lombardo L, Siciliani G. Description of the relationship between NOHL classification in drug-induced sleep endoscopy and initial AHI in patients with moderate to severe OSAS, and evaluation of the results obtained with oral appliance therapy. ACTA ACUST UNITED AC 2019; 40:50-56. [PMID: 31570902 PMCID: PMC7147537 DOI: 10.14639/0392-100x-2290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/30/2018] [Indexed: 11/23/2022]
Abstract
Nowadays, drug-induced sleep endoscopy is widely recognised as a valid tool for diagnosis and treatment planning of obstructive sleep apnoea syndrome (OSAS), as it allows a direct visualisation of sites and patterns of collapse of the upper airways (UA). Various classifications have been proposed in the literature to describe the events observed during DISE, including the NOHL (Nasopharynx cavity and walls, Oropharynx, Hypopharynx, Larynx) classification. This study was aimed at assessing which anatomical structures, according to the NOHL Classification, were most frequently involved in UA collapse in patients with moderate to severe OSAS, and evaluating treatment results with oral appliances (OA), in terms of AHI reduction. The study group consisted of 35 patients (29 M, 6 F, mean age 50.6, average BMI 26) with polysomnographic diagnosis of moderate to severe OSAS, subjected to DISE and classified according to the NOHL classification to identify the anatomical sites and patterns of UA collapse most frequently reported. Patients were subsequently addressed to mandibular advancing device (MAD) therapy and treatment results in terms of AHI reduction were evaluated. In the sample examined, the anatomical structures most frequently involved in the collapse of the UA were the nasopharynx cavity and walls and tongue base, with a correlation index of 0.35 (p < 0.04), while no significance was found for the retro-palatal area or larynx. Descriptive analysis revealed multilevel collapse in all patients, involving multiple anatomical structures in obstructive mechanics. In all patients, AHI reduction was observed after treatment with MAD (p < 0.00).
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Affiliation(s)
- Claudio Vicini
- Department of Otolaryngology, Ospedale Morgani-Pierantoni, Forlì, Italy
| | | | | | | | | | - Luca Lombardo
- Department of Orthodontics, University of Ferrara, Italy
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Memtsoudis SG, Cozowicz C, Nagappa M, Wong J, Joshi GP, Wong DT, Doufas AG, Yilmaz M, Stein MH, Krajewski ML, Singh M, Pichler L, Ramachandran SK, Chung F. Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea. Anesth Analg 2019; 127:967-987. [PMID: 29944522 PMCID: PMC6135479 DOI: 10.1213/ane.0000000000003434] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.
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Affiliation(s)
- Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Crispiana Cozowicz
- From the Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St Joseph's Health Care, Western University, London, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, Texas
| | - David T Wong
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Anthony G Doufas
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Palo Alto, California
| | - Meltem Yilmaz
- Department of Anesthesiology, Northwestern University, Chicago, Illinois
| | - Mark H Stein
- Department of Anesthesiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Megan L Krajewski
- Department of Anesthesia, Critical Care, and Pain Management, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mandeep Singh
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Toronto Sleep and Pulmonary Centre, Toronto, Canada.,Department of Anesthesia and Pain Management, Women's College Hospital, Toronto, Canada.,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lukas Pichler
- From the Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Satya Krishna Ramachandran
- Department of Anesthesiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Madeiro F, Andrade RGS, Piccin VS, Pinheiro GDL, Moriya HT, Genta PR, Lorenzi-Filho G. Transmission of Oral Pressure Compromises Oronasal CPAP Efficacy in the Treatment of OSA. Chest 2019; 156:1187-1194. [PMID: 31238041 DOI: 10.1016/j.chest.2019.05.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 04/27/2019] [Accepted: 05/27/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND An oronasal mask is frequently used to treat OSA. In contrast to nasal CPAP, the effectiveness of oronasal CPAP varies by unknown mechanisms. We hypothesized that oral breathing and pressure transmission through the mouth compromises oronasal CPAP efficacy. METHODS Thirteen patients with OSA, well adapted to oronasal CPAP, were monitored by full polysomnography, pharyngeal pressure catheter, and nasoendoscope. Patients slept with low doses of midazolam, using an oronasal mask with sealed nasal and oral compartments. CPAP was titrated during administration by the oronasal and nasal routes, and was then reduced to induce stable flow limitation and abruptly switched to the alternate route. In addition, tape sealing the mouth was used to block pressure transmission to the oral cavity. RESULTS Best titrated CPAP was significantly higher by the oronasal route rather than the nasal route (P = .005), and patients with > 25% oral breathing (n = 5) failed to achieve stable breathing during oronasal CPAP. During stable flow limitation, inspiratory peak flow was lower, driving pressure was higher, upper airway inspiratory resistance was higher, and retropalatal and retroglossal area were smaller by the oronasal rather than nasal route (P < .05 for all comparisons). Differences were observed even among patients with no oral flow and were abolished when tape sealing the mouth was used (n = 6). CONCLUSIONS Oral breathing and transmission of positive pressure through the mouth compromise oronasal CPAP.
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Affiliation(s)
- Fernanda Madeiro
- Laboratório do Sono, Divisão de Pneumologia, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Rafaela G S Andrade
- Laboratório do Sono, Divisão de Pneumologia, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Vivien S Piccin
- Laboratório do Sono, Divisão de Pneumologia, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - George do Lago Pinheiro
- Laboratório do Sono, Divisão de Pneumologia, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Henrique T Moriya
- Laboratório de Engenharia Biomédica, Escola Politécnica, Universidade de São Paulo, São Paulo, Brazil
| | - Pedro R Genta
- Laboratório do Sono, Divisão de Pneumologia, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Laboratório do Sono, Divisão de Pneumologia, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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Babademez MA, Gul F, Teleke YC. Barbed palatoplasty vs. expansion sphincter pharyngoplasty with anterior palatoplasty. Laryngoscope 2019; 130:E275-E279. [PMID: 31188473 DOI: 10.1002/lary.28136] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/09/2019] [Accepted: 05/28/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE/HYPOTHESIS To compare the functional outcomes and complication rates in patients who underwent expansion sphincter pharyngoplasty with anterior palatoplasty (ESPwAP) versus barbed pharyngoplasty (BP). STUDY DESIGN Retrospective cohort study. METHODS A medical database was used to retrieve the records of 129 patients who had an isolated palatoplasty surgery between January 2014 and July 2018. Patients who had mild or moderate obstructive sleep apnea without a history of revision surgery and underwent ESPwAP or BP in addition to traditional tonsillectomy were included in the study. Pre- and postoperative polysomnography and Epworth Sleepiness Scale (ESS) was evaluated in the patients who completed at least a 6-month follow-up period. RESULTS Forty-five and 53 patients met the inclusion, and were comprised of BP and ESPwAP groups, respectively. ESPwAP and BP significantly improved mean apnea hypopnea index (AHI) from 28.5 to 9.1 (P = .000) and 25.9 to 7.4 (P = .000), respectively. No significant statistical difference was found between the mean AHI scores of two groups. Selecting a threshold of a 50% reduction in AHI and AHI less than 20 events/h, success rates were 86.6% in BP group and 84.9% in ESPwAP group. CONCLUSIONS Our study showed that both types of surgeries are effective with comparable results. The BP technique may be preferred when possible to avoid soft tissue excision and seems to be a less invasive procedure with a similar success rate when compared to ESPwAP. LEVEL OF EVIDENCE 4 Laryngoscope, 130:E275-E279, 2020.
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Affiliation(s)
- Mehmet Ali Babademez
- Department of Otorhinolaryngology, Yıldırım Beyazıt University School of Medicine, Head and Neck Surgery, Ankara, Turkey
| | - Fatih Gul
- Department of Otorhinolaryngology, Yıldırım Beyazıt University School of Medicine, Head and Neck Surgery, Ankara, Turkey
| | - Yagmur Canan Teleke
- Department of Otorhinolaryngology, Yıldırım Beyazıt University School of Medicine, Head and Neck Surgery, Ankara, Turkey
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Lai V, Tong BK, Tran C, Ricciardiello A, Donegan M, Murray NP, Carberry JC, Eckert DJ. Combination therapy with mandibular advancement and expiratory positive airway pressure valves reduces obstructive sleep apnea severity. Sleep 2019; 42:5513371. [DOI: 10.1093/sleep/zsz119] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/07/2019] [Indexed: 12/21/2022] Open
Abstract
AbstractStudy ObjectivesMandibular advancement splint (MAS) therapy is a well-tolerated alternative to continuous positive airway pressure for obstructive sleep apnea (OSA). Other therapies, including nasal expiratory positive airway pressure (EPAP) valves, can also reduce OSA severity. However, >50% of patients have an incomplete or no therapeutic response with either therapy alone and thus remain at risk of adverse health outcomes. Combining these therapies may yield greater efficacy to provide a therapeutic solution for many incomplete/nonresponders to MAS therapy. Thus, this study evaluated the efficacy of combination therapy with MAS plus EPAP in incomplete/nonresponders to MAS alone.MethodsTwenty-two people with OSA (apnea–hypopnea index [AHI] = 22 [13, 42] events/hr), who were incomplete/nonresponders (residual AHI > 5 events/hr) on an initial split-night polysomnography with a novel MAS device containing an oral airway, completed an additional split-night polysomnography with MAS + oral EPAP valve and MAS + oral and nasal EPAP valves (order randomized).ResultsCompared with MAS alone, MAS + oral EPAP significantly reduced the median total AHI, with further reductions with the MAS + oral/nasal EPAP combination (15 [10, 34] vs. 10 [7, 21] vs. 7 [3, 13] events/hr, p < 0.01). Larger reductions occurred in supine nonrapid eye movement AHI with MAS + oral/nasal EPAP combination therapy (ΔAHI = 23 events/hr, p < 0.01). OSA resolved (AHI < 5 events/hr) with MAS + oral/nasal EPAP in nine individuals and 13 had ≥50% reduction in AHI from no MAS. However, sleep efficiency was lower with MAS + oral/nasal EPAP versus MAS alone or MAS + oral EPAP (78 ± 19 vs. 87 ± 10 and 88 ± 10% respectively, p < 0.05).ConclusionsCombination therapy with a novel MAS device and simple oral or oro-nasal EPAP valves reduces OSA severity to therapeutic levels for a substantial proportion of incomplete/nonresponders to MAS therapy alone.Clinical TrialsName: Targeted combination therapy: Physiological mechanistic studies to inform treatment for obstructive sleep apnea (OSA)URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372279 Registration: ACTRN12617000492358 (Part C)
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Affiliation(s)
- Victor Lai
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Benjamin K Tong
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Carolin Tran
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
| | | | | | | | - Jayne C Carberry
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
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82
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Adult sleep apnea and tonsil hypertrophy: should pharyngoplasty be associated with tonsillectomy? Sleep Breath 2019; 23:917-923. [PMID: 31115738 DOI: 10.1007/s11325-019-01864-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 04/16/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Velopharyngoplasty and palatine tonsillectomy are at the very heart of the surgical treatment of obstructive sleep apnea syndrome (OSAS) care. In cases of major tonsil hypertrophy, we evaluated the relevance of associating soft palate surgery with palatine tonsillectomy, independent of the soft palate length. METHODS We conducted a retrospective single-center study in OSAS patients with grade III or IV tonsils treated with tonsillectomy. Preoperative assessment included an upper airway examination performed while the patient was awake, a polysomnography and a drug-induced sedation endoscopy (DISE). Surgical efficacy was assessed on postoperative polysomnography. Success was considered when the postoperative apnea-hypopnea index (AHI) was less than 20 events/h with a 50% reduction. We compared palatine tonsillectomy efficacy alone (group A) and associated with soft palate surgery (group B). RESULTS We analyzed 33 patients who had undergone surgery between December 2006 and May 2018. Their preoperative mean BMI and mean AHI were 27.3 ± 7.5 kg/m2 and 38.6 ± 21.4 events/h, respectively. The two groups (A, n = 18 and B, n = 15) were clinically comparable. The success rate was 72.2% in group A and 60% in group B. There was no statistically significant difference between the two groups (p > 0.1). CONCLUSIONS According to this study, in our institution, in cases of major tonsillar hypertrophy, simultaneous soft palate surgery had no significant impact on the success rate, regardless of soft palate length. Associating soft palate surgery with palatine tonsillectomy does not seem mandatory to increase the success rate. LEVEL OF EVIDENCE III. Retrospective comparative study.
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83
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Barbieri M, Missale F, Incandela F, Fragale M, Barbieri A, Roustan V, Canevari FR, Peretti G. Barbed suspension pharyngoplasty for treatment of lateral pharyngeal wall and palatal collapse in patients affected by OSAHS. Eur Arch Otorhinolaryngol 2019; 276:1829-1835. [PMID: 30993468 DOI: 10.1007/s00405-019-05426-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/09/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study is to analyze the efficacy of a new modified pharyngoplasty technique with barbed sutures: barbed suspension pharyngoplasty (BSP). METHODS We enrolled patients affected by obstructive sleep apnea-hypopnea syndrome (OSAHS), having the main site of obstruction at the palatal and lateral pharyngeal walls, who refused or failed to tolerate CPAP therapy and underwent non-resective pharyngoplasty with barbed sutures between January 2014 and October 2017. Two surgical techniques with barbed sutures were used: barbed reposition pharyngoplasty (BRP) and BSP; the main characteristics of the latter are a double passage of the needle, each side, through the soft palate. RESULTS Forty-two patients met the study inclusion criteria and were included in the analysis. Twenty-two patients underwent BRP and 20 BSP. Patients treated with both BRP and BSP achieved significant improvement in polysomnographic parameters: AHI, ODI, t90%, and daily sleepiness tested by the ESS questionnaire (p < 0.001). There were no significant differences between groups considering gender, age, or severity of OSAHS (p > 0.05). Outcomes were also comparable (p = 0.10) in the two groups; patients who underwent BSP had successful treatment in 100% of cases, compared to 86% with BRP, with a cure rate of 40% vs. 18%. CONCLUSIONS BSP is a novel surgical technique that is effective in treating oropharyngeal collapse and can be tailored for patients with high collapsibility of the soft palate who might benefit from the palatal stiffness given by multiple passages of the suture inside it.
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Affiliation(s)
- Marco Barbieri
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Francesco Missale
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy.
| | - Fabiola Incandela
- Department of Otorhinolaryngology, Maxillofacial and Thyroid Surgery, Fondazione IRCCS, National Cancer Institute of Milan, University of Milan, Milan, Italy
| | - Marco Fragale
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Andrea Barbieri
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Valeria Roustan
- Department of Otorhinolaryngology, Ospedale Santa Maria Delle Croci, Ravenna, Italy
| | - Frank Rikki Canevari
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
| | - Giorgio Peretti
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Genoa, Genoa, Italy
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84
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Mahmoud AF, Thaler ER. Outcomes of Hypoglossal Nerve Upper Airway Stimulation among Patients with Isolated Retropalatal Collapse. Otolaryngol Head Neck Surg 2019; 160:1124-1129. [DOI: 10.1177/0194599819835186] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective To examine whether patients with isolated retropalatal collapse perform as well as others following implantation with an upper airway stimulation (UAS) device. Study Design Retrospective review. Setting Single-institution tertiary academic care medical center. Subjects and Methods Following drug-induced sleep endoscopy, subjects who met inclusion criteria for implantation with a UAS device received an implant per industry standard. Subjects with isolated retropalatal collapse were compared with those having other patterns of collapse. Outcome measures included apnea-hypopnea index (AHI) and nadir oxyhemoglobin saturation (NOS). Results Ninety-one patients were implanted during the duration of the study, and 82 met inclusion criteria for analysis. Twenty-five had isolated retropalatal collapse, while the remaining 57 had other patterns of collapse on drug-induced sleep endoscopy. For all patients, mean preoperative AHI and NOS were 38.7 (95% CI, 35.0-42.4) and 78% (95% CI, 75%-80%), respectively; these improved postoperatively to 4.5 (95% CI, 2.3-6.6) and 91% (95% CI, 91%-92%). There was no significant preoperative difference between groups with regard to demographics, AHI, or NOS. Group comparison showed postoperative AHI to be 5.7 (95% CI, 0.57-10.8) for patients with isolated retropalatal collapse and 3.9 (95% CI, 1.7-6.1) for other patients ( P = .888). Postoperative NOS was 92% (95% CI, 90%-94%) among patients with isolated retropalatal collapse and 91% (95% CI, 90%-92%) for others ( P = .402). Conclusions All patients showed significant improvement following implantation with UAS. Patients with isolated retropalatal collapse showed similar improvement to other types of collapse with regard to AHI and NOS.
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Affiliation(s)
- Ahmad F. Mahmoud
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica R. Thaler
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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85
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de Bruin IJA, Klop C, Wyers CE, Overbeek JA, Geusens PPMM, van den Bergh JPW, Driessen JHM, de Vries F. All-cause mortality with current and past use of antidepressants or benzodiazepines after major osteoporotic and hip fracture. Osteoporos Int 2019; 30:573-581. [PMID: 30737577 PMCID: PMC6422967 DOI: 10.1007/s00198-019-04851-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/10/2019] [Indexed: 01/22/2023]
Abstract
UNLABELLED In the first year, after an osteoporotic fracture of a hip, forearm, upper arm, or spine, the dispensing rates of antidepressants and benzodiazepines increased significantly. After those fractures, recent and past use of antidepressants and benzodiazepines was associated with increased all-cause mortality; current use was not associated with mortality risk. INTRODUCTION It remains unclear to what extent use of antidepressants and benzodiazepines is associated with mortality risk after a major osteoporotic fracture (MOF). We aimed to study the cumulative use of antidepressants and benzodiazepines during the year after MOF or hip fracture (HF) and whether the use was associated with mortality. METHODS A cohort study was performed within the Dutch PHARMO Database Network including all patients aged 65+ with a first record of MOF (hip, humerus, forearm, and clinical vertebral fracture) between 2002 and 2011. Data were analyzed using Cox regression models, adjusted for comorbidities, and concomitant medication use and broken down to index fracture type. RESULTS A total of 4854 patients sustained a first MOF, of whom 1766 patients sustained a HF. Mean follow-up was 4.6 years, divided in 30-day periods. The cumulative antidepressant and benzodiazepine use during the first year after MOF increased from 10.6 to 14.7% and from 24.0 to 31.4%, respectively. Recent (31-92 days before each follow-up period) and past use (> 92 days before) of antidepressants and benzodiazepines after MOF or HF was associated with an increased all-cause mortality risk but current use (< 30 days before) was not. CONCLUSION There is a considerable increase in dispensing rate of antidepressants and benzodiazepines in the first year after a MOF. Recent and past use of these medications was associated with all-cause mortality. The finding that current use was not associated with mortality should be further explored and may probably be explained by the healthy survivor's bias.
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Affiliation(s)
- I J A de Bruin
- Department of Internal Medicine, VieCuri Medical Center, Venlo, Netherlands
- NUTRIM, Department of Internal Medicine, Maastricht University Medical Center +, Maastricht, Netherlands
| | - C Klop
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - C E Wyers
- Department of Internal Medicine, VieCuri Medical Center, Venlo, Netherlands
- NUTRIM, Department of Internal Medicine, Maastricht University Medical Center +, Maastricht, Netherlands
| | - J A Overbeek
- PHARMO Institute for Drug Outcome Research, Utrecht, Netherlands
| | - P P M M Geusens
- Biomedical Research Center, Hasselt University, Diepenbeek, Belgium
- CAPHRI, Department of Internal Medicine, Subdivision Rheumatology, Maastricht University Medical Center +, Maastricht, Netherlands
| | - J P W van den Bergh
- Department of Internal Medicine, VieCuri Medical Center, Venlo, Netherlands
- NUTRIM, Department of Internal Medicine, Maastricht University Medical Center +, Maastricht, Netherlands
- Biomedical Research Center, Hasselt University, Diepenbeek, Belgium
| | - J H M Driessen
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
- NUTRIM/CAPHRI, Maastricht University Medical Center +, Maastricht, Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center +, P Debyelaan 25, Maastricht, Netherlands
| | - F de Vries
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands.
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center +, P Debyelaan 25, Maastricht, Netherlands.
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK.
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86
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A Bag of Wavelet Features for Snore Sound Classification. Ann Biomed Eng 2019; 47:1000-1011. [DOI: 10.1007/s10439-019-02217-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
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87
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Heiser C, Steffen A, Boon M, Hofauer B, Doghramji K, Maurer JT, Sommer JU, Soose R, Strollo PJ, Schwab R, Thaler E, Withrow K, Kominsky A, Larsen C, Kezirian EJ, Hsia J, Chia S, Harwick J, Strohl K, Mehra R. Post-approval upper airway stimulation predictors of treatment effectiveness in the ADHERE registry. Eur Respir J 2019; 53:13993003.01405-2018. [PMID: 30487205 PMCID: PMC6319796 DOI: 10.1183/13993003.01405-2018] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/19/2018] [Indexed: 02/05/2023]
Abstract
Upper airway stimulation (UAS) has been shown to reduce severity of obstructive sleep apnoea. The aim of this study was to identify predictors of UAS therapy response in an international multicentre registry.Patients who underwent UAS implantation in the United States and Germany were enrolled in an observational registry. Data collected included patient characteristics, apnoea/hypopnoea index (AHI), Epworth sleepiness scale (ESS), objective adherence, adverse events and patient satisfaction measures. Post hoc univariate and multiple logistic regression were performed to evaluate factors associated with treatment success.Between October 2016 and January 2018, 508 participants were enrolled from 14 centres. Median AHI was reduced from 34 to 7 events·h-1, median ESS reduced from 12 to 7 from baseline to final visit at 12-month post-implant. In post hoc analyses, for each 1-year increase in age, there was a 4% increase in odds of treatment success. For each 1-unit increase in body mass index (BMI), there was 9% reduced odds of treatment success. In the multivariable model, age persisted in serving as statistically significant predictor of treatment success.In a large multicentre international registry, UAS is an effective treatment option with high patient satisfaction and low adverse events. Increasing age and reduced BMI are predictors of treatment response.
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Affiliation(s)
- Clemens Heiser
- Dept of Otorhinolaryngology, Head and Neck Surgery, Munich Technical University, Munich, Germany
| | - Armin Steffen
- Dept of Otorhinolaryngology, University of Lubeck, Lubeck, Germany
| | - Maurits Boon
- Dept of Otorhinolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Benedikt Hofauer
- Dept of Otorhinolaryngology, Head and Neck Surgery, Munich Technical University, Munich, Germany
| | - Karl Doghramji
- Dept of Otorhinolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joachim T Maurer
- Dept of Otorhinolaryngology, Head and Neck Surgery, HELIOS University Hospital Wuppertal, Wuppertal, Germany
| | - J Ulrich Sommer
- Dept of Otorhinolaryngology, Head and Neck Surgery, HELIOS University Hospital Wuppertal, Wuppertal, Germany
| | - Ryan Soose
- Dept of Otorhinolaryngology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Strollo
- Dept of Otorhinolaryngology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard Schwab
- Dept of Sleep Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Erica Thaler
- Dept of Sleep Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kirk Withrow
- Dept of Otorhinolaryngology, University of Alabama, Birmingham, AL, USA
| | - Alan Kominsky
- Dept of Otorhinolaryngology, Cleveland Clinic, Cleveland, OH, USA
| | - Christopher Larsen
- Dept of Otorhinolaryngology - Head and Neck Surgery, Kansas University Medical Center, Kansas City, KS, USA
| | - Eric J Kezirian
- Dept of Otorhinolaryngology - Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Jennifer Hsia
- Dept of Otorhinolaryngology - Head and Neck Surgery, University of Minnesota Fairview Hospital, Minneapolis, MN, USA
| | - Stanley Chia
- Dept of Otorhinolaryngology, MedStar Washington Hospital Center, Washington, DC, USA
| | - John Harwick
- Dept of Otorhinolaryngology - Head and Neck Surgery, University of Florida, Gainesville, FL, USA
| | - Kingman Strohl
- Dept of Pulmonary and Critical Care Medicine and Sleep Medicine, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Reena Mehra
- Dept of Otorhinolaryngology, Cleveland Clinic, Cleveland, OH, USA
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88
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Lee EJ, Cho JH. Meta‐Analysis of Obstruction Site Observed With Drug‐Induced Sleep Endoscopy in Patients With Obstructive Sleep Apnea. Laryngoscope 2018; 129:1235-1243. [DOI: 10.1002/lary.27320] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Eun Jung Lee
- Department of OtorhinolaryngologyYonsei University College of Medicine Seoul Republic of Korea
| | - Jae Hoon Cho
- Department of Otorhinolaryngology–Head and Neck Surgery, College of MedicineKonkuk University Seoul Republic of Korea
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89
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De Vito A, Carrasco Llatas M, Ravesloot MJ, Kotecha B, De Vries N, Hamans E, Maurer J, Bosi M, Blumen M, Heiser C, Herzog M, Montevecchi F, Corso RM, Braghiroli A, Gobbi R, Vroegop A, Vonk PE, Hohenhorst W, Piccin O, Sorrenti G, Vanderveken OM, Vicini C. European position paper on drug-induced sleep endoscopy: 2017 Update. Clin Otolaryngol 2018; 43:1541-1552. [PMID: 30133943 DOI: 10.1111/coa.13213] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/14/2018] [Accepted: 08/20/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The first edition of the European position paper (EPP) on drug-induced sleep endoscopy (DISE) was published in 2014 with the aim to standardise the procedure, to provide an in-depth insight into the main aspects of this technique and to have a basis for future research. Since 2014, new studies have been published concerning new sedative agents or new insights into the pattern/levels of the obstruction depending on the depth of sedation. Therefore, an enlarged group of European experts in the field of sleep breathing disorders (SBD), including the most of the first DISE EPP main authors, has decided to publish an update of the European position paper on DISE, in order to include new evidence and to find a common language useful for reporting the findings of this endoscopic evaluation in adult population affected by SBD. METHODS The authors have evaluated all the available evidence reported in the literature and have compared experience among various departments in leading European centres in order to provide an update regarding the standardisation of the DISE procedure and an in-depth insight into the main aspects of this technique. RESULTS After the first European Position Consensus Meeting on DISE and its update, consensus was confirmed for indications, required preliminary examinations, where to perform DISE, technical equipment required, staffing, local anaesthesia, nasal decongestion, other medications, patient positioning, basics and special diagnostic manoeuvres, drugs and observation windows. So far, no consensus could be reached on a scoring and classification system. However, regarding this aim, the idea of an essential classification, such as VOTE with the possibility of its graded implementation of information and descriptions, seems to be the best way to reach a universal consensus on DISE classification at this stage. A common DISE language is mandatory, and attempts to come to a generally accepted system should be pursued.
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Affiliation(s)
- Andrea De Vito
- Head and Neck Department, ENT & Oral Surgery Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,ENT Unit, Santa Maria delle Croci Hospital, Ravenna AUSL of Romagna, Romagna, Italy
| | | | - Madeline J Ravesloot
- Department of Otorhinolaryngology and Head and Neck Surgery, OLVG, Amsterdam, The Netherlands.,Medisch Centrum Jan van Goyen, Amsterdam, The Netherlands
| | - Bhik Kotecha
- Royal National Throat Nose & Ear Hospital, UCLH, London, UK
| | - Nico De Vries
- Department of Otolaryngology, OLVG Hospital and ACTA, Amsterdam, Netherlands.,Department of Otorhinolaryngology and Head and Neck Surgery, Multidisciplinary Sleep Disorders Center, University of Antwerp, Antwerp, Belgium.,Department of Oral Kinesiology, Academic Centre for Dentistry, MOVE Inst., Amsterdam, The Netherlands
| | - Evert Hamans
- Department of Otorhinolaryngology, Head and Neck Surgery, Jan Palfijn Hospital, Ziekenhuis Netwerk Antwerpen (ZNA), Antwerpen, Belgium
| | - Joachim Maurer
- Sleep Disorders Centre, Department of Otorhinolaryngology, Head and Neck Surgery, University Medicine Mannheim, Mannheim, Germany
| | - Marcello Bosi
- Pulmonary Operative Unit, Department of Thoracic Diseases, Morgagni-Pierantoni Hospital, AUSL of Romagna, Forlì, Italy
| | - Marc Blumen
- Service ORL, Hopital Foch, Suresnes France and Centre Medical Veille Sommeil, Paris, France
| | - Clemens Heiser
- Department of Otorhinolaryngology, Head and Neck Surgery, Technische Universitat Munchen, Munich, Germany
| | - Michael Herzog
- Department of Otorhinolaryngology, Head and Neck Surgery, Carl Thiem Klinikum, Cottbus, Germany
| | - Filippo Montevecchi
- Head and Neck Department, ENT & Oral Surgery Unit, Morgagni-Pierantoni Hospital, AUSL of Romagna, Forlì, Italy
| | | | - Alberto Braghiroli
- Sleep Lab. Pulmonary Rehabilitation Dept. Istituti Clinici Scientifici Maugeri, SPA SB, IRCCS, Veruno, Italy
| | - Riccardo Gobbi
- Head and Neck Department, ENT & Oral Surgery Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Anneclaire Vroegop
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Patty Elisabeth Vonk
- Department of Otorhinolaryngology and Head and Neck Surgery, OLVG, Amsterdam, The Netherlands
| | | | - Ottavio Piccin
- Department of Otolaryngology, Head and Neck Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giovanni Sorrenti
- Department of Otolaryngology, Head and Neck Surgery, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Olivier M Vanderveken
- Faculty of Medicine and Health Sciences, University of Antwerp- Department ENT, Head and Neck Surgery, Antwerp University Hospital - Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Antwerp, Belgium
| | - Claudio Vicini
- Head and Neck Department, AUSL of Romagna, ENT & Oral Surgery Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,ENT Unit, Infermi Hospital, AUSL of Romagna, Faenza, Italy.,ENT Unit, Santa Maria delle Croci Hospital, Ravenna, Italy.,AUSL of Romagna, Romagna, Italy.,ENT Clinic, University of Ferrara, Ferrara, Italy
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90
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Prediction of tongue obstruction observed from drug induced sleep computed tomography by cephalometric parameters. Auris Nasus Larynx 2018; 46:384-389. [PMID: 30262210 DOI: 10.1016/j.anl.2018.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/15/2018] [Accepted: 08/26/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To elucidate potential role of cephalometric measurements to predict tongue base obstruction as observed on drug Induced Sleep Computed Tomography (DIS-CT). METHODS Study included 35 patients with moderate to severe sleep apnea who underwent DIS-CT & cephalometric examination to assess tongue base obstruction. RESULTS Statistically significant difference was noted for SNA angle & Mandibular posterior airway space (PAS) among groups with total tongue obstruction versus Non-total tongue obstruction identified on DIS-CT. CONCLUSION Lateral cephalogram can be used as a standard screening tool with commonly used skeletal and soft tissue parameters to predict the possibility of tongue collapse/obstruction during sleep in patient with moderate to severe OSAS.
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91
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Zhao C, Viana A, Ma Y, Capasso R. The effect of aging on drug-induced sleep endoscopy findings. Laryngoscope 2018; 128:2644-2650. [PMID: 30194857 DOI: 10.1002/lary.27265] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 03/03/2018] [Accepted: 04/09/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the correlation of aging and upper airway collapse characteristics observed by drug-induced sleep endoscopy (DISE), and report the observed differences on obstructive sleep apnea (OSA) subjects, older and younger than 60 years. STUDY DESIGN Case series. METHODS This study analyzed the data of 200 OSA patients who underwent DISE between January 1, 2013 and June 30, 2017. The variables sex, body mass index (BMI), Epworth Sleepiness Scale score, tonsil size, modified Mallampati (MM) classification, apnea-hypopnea index (AHI), oxygen desaturation index (ODI), lowest oxygen saturation, and VOTE (velum, oropharynx, tongue base, epiglottis) classification were compared between two groups: <60 and ≥60 years old. RESULTS Older age had significant correlation with higher AHI, ODI, lower O2 nadir, multisite obstruction, combined upper (palatopharyngeal) + lower (hypopharyngeal) level obstructions, and complete anterior-posterior (AP) velum collapse pattern. Lateral oropharyngeal wall collapse was significantly lower in the older group. Findings remained statistically significant when adjusted for sex, BMI, tonsil size, and MM. CONCLUSIONS Aging was an independent factor that directly correlated with increased AHI and hypoxemia, multisites, combined levels of obstruction, and complete AP velum collapse pattern. Being older than 60 years had higher of complete AP velum collapse and lower incidence of lateral oropharyngeal wall collapse, regardless of OSA severity and tonsil size. LEVEL OF EVIDENCE 4 Laryngoscope, 2644-2650, 2018.
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Affiliation(s)
- Chen Zhao
- Department of Otorhinolaryngology, First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China.,Division of Sleep Surgery, Stanford, California, U.S.A
| | - Alonço Viana
- Division of Sleep Surgery, Stanford, California, U.S.A.,Graduate Program of Neurology, Rio de Janeiro State Federal University, Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Marcílio Dias Naval Hospital, Rio de Janeiro, Brazil
| | - Yifei Ma
- Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, California, U.S.A
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92
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Viana A, Zhao C, Rosa T, Couto A, Neves DD, Araújo-Melo MH, Capasso R. The Effect of Sedating Agents on Drug-Induced Sleep Endoscopy Findings. Laryngoscope 2018; 129:506-513. [PMID: 30194726 DOI: 10.1002/lary.27298] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Drug-induced sleep endoscopy (DISE) has gained interest for upper airway evaluation in patients with snoring and obstructive sleep apnea (OSA), and different drugs have been used to induce sedation. Nevertheless, all drugs have presented specific advantages and disadvantages with differential effects on respiratory physiology. This study evaluated and compared the effects of midazolam, propofol and dexmedetomidine on DISE findings, O2 nadir, and bispectral index (BIS) in the same sample of patients. STUDY DESIGN Case series prospective study. METHODS Consecutive patients who elected to undergo surgery for OSA treatment and were intolerant to conservative therapies underwent DISE with propofol, dexmedetomidine, and midazolam between July 2015 and July 2016. RESULTS Fifty-two patients were analyzed, and 43 (82.7%) were men. Agreement among drugs for both degree and patterns of obstruction was excellent at all sites (velum, oropharynx, and epiglottis) except for the tongue base. Dexmedetomidine had the least complete collapse sites and highest O2 nadir and was the only drug for which apnea severity and obstruction levels (upper, lower, or combined) were correlated. The variability among drug treatments for the BIS index was considerable, and propofol had the lowest variability and average value. CONCLUSION Drug selection had a relevant influence in DISE findings. Compared with dexmedetomidine, midazolam and propofol presented higher incidence of tongue base collapse, lower O2 levels, and lower BIS index values. Propofol resulted in an O2 nadir that most resembled that observed during polysomnography. The BIS index variability differed among drugs, and its use was considered relevant for sedation orientation. LEVEL OF EVIDENCE 4 Laryngoscope, 129:506-513, 2019.
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Affiliation(s)
- Alonço Viana
- Program of Neurology, Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Marcílio Dias Naval Hospital (HNMD), Rio de Janeiro, Brazil.,Department of Otolaryngology-Head and Neck Surgery, Division of Sleep Surgery, Stanford University, Stanford, California, U.S.A
| | - Chen Zhao
- Department of Otolaryngology-Head and Neck Surgery, Division of Sleep Surgery, Stanford University, Stanford, California, U.S.A.,Department of Otorhinolaryngology, First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Talita Rosa
- Department of Neurology, University of California, San Francisco, California, U.S.A
| | - Arnaldo Couto
- Department of Pharmacy, West Zone Rio de Janeiro State University (UEZO), Rio de Janeiro, Brazil
| | - Denise Duprat Neves
- Program of Neurology, Rio de Janeiro, Brazil.,Department of Cardiopulmonary, Rio de Janeiro, Brazil
| | - Maria Helena Araújo-Melo
- Program of Neurology, Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Robson Capasso
- Department of Otolaryngology-Head and Neck Surgery, Division of Sleep Surgery, Stanford University, Stanford, California, U.S.A
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Schlafendoskopie und komplett konzentrischer Weichgaumenkollaps bei CPAP-Nutzungsproblemen. HNO 2018; 66:837-842. [DOI: 10.1007/s00106-018-0550-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Kastoer C, Benoist LBL, Dieltjens M, Torensma B, de Vries LH, Vonk PE, Ravesloot MJL, de Vries N. Comparison of upper airway collapse patterns and its clinical significance: drug-induced sleep endoscopy in patients without obstructive sleep apnea, positional and non-positional obstructive sleep apnea. Sleep Breath 2018; 22:939-948. [PMID: 30069673 DOI: 10.1007/s11325-018-1702-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/19/2018] [Accepted: 07/16/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE To compare patient characteristics, upper airway (UA) collapse patterns and treatment outcome in obstructive sleep apnea (OSA) patients, including non-positional OSA patients (NPP) and positional OSA patients (PP), and non-OSA. METHODS Cohort study of patients screened for OSA in 2012. Polysomnography was performed and UA was evaluated using the VOTE classification during drug-induced sleep endoscopy (DISE). Treatment outcome of MAD and UA surgery was evaluated. RESULTS Eight hundred sixty patients were included. Higher BMI, larger neck circumference, and greater age were independent significant predictors for OSA. DISE was performed in 543 patients: 119 non-OSA and 424 OSA patients of whom 257 PP and 167 NPP patients. PP were younger, had smaller neck circumference, lower BMI and apnea-hypopnea index (AHI) than NPP. Collapse at velum (p < 0.001) and oropharynx (p < 0.001) significantly increased the odds for having OSA. Tongue base and epiglottis collapse were, on group level, not determinative for OSA or non-OSA. Complete concentric collapse (CCC) was observed less frequently in PP (31.5%) as compared to NPP (46.1%). After UA surgery, OSA often was cured or improved to less severe positional OSA. Lower efficacy of UA surgery was observed in PP as compared to NPP. No differences were observed in MAD treatment outcome. CONCLUSIONS Current study provides insight in patients screened for OSA: collapse at velum and oropharynx significantly determined presence of OSA and CCC occurred less frequently in PP compared to NPP. In addition, residual positional dependency is common after UA surgery. More trials are needed to gain insight in pathophysiology and treatment outcome.
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Affiliation(s)
- C Kastoer
- Department of Otolaryngology Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium. .,Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium. .,Department of Otorhinolaryngology Head and Neck Surgery, OLVG West, Amsterdam, The Netherlands.
| | - L B L Benoist
- Department of Otorhinolaryngology Head and Neck Surgery, OLVG West, Amsterdam, The Netherlands.,Department of Otorhinolaryngology Head and Neck Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M Dieltjens
- Department of Otolaryngology Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium.,Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium
| | - B Torensma
- Department of Anaesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - L H de Vries
- Department of Otorhinolaryngology Head and Neck Surgery, OLVG West, Amsterdam, The Netherlands
| | - P E Vonk
- Department of Otorhinolaryngology Head and Neck Surgery, OLVG West, Amsterdam, The Netherlands
| | - M J L Ravesloot
- Department of Otorhinolaryngology Head and Neck Surgery, OLVG West, Amsterdam, The Netherlands.,Department of Otolaryngology Medical Centre Jan van Goyen, Amsterdam, The Netherlands
| | - N de Vries
- Department of Otolaryngology Head and Neck Surgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Antwerp, Belgium.,Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Antwerp, Belgium.,Department of Otorhinolaryngology Head and Neck Surgery, OLVG West, Amsterdam, The Netherlands.,Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
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95
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Radiographic and histologic characterization of tongue base tissues obtained by transoral robotic surgery in patients with obstructive sleep apnea. Auris Nasus Larynx 2018; 46:89-94. [PMID: 29929870 DOI: 10.1016/j.anl.2018.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/04/2018] [Accepted: 06/11/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Our aim was to radiographically and histologically characterize the tongue base tissues removed after robotic surgery and to analyze their relationship with polysomnographic measurements in obstructive sleep apnea. METHODS Medical records, radiographs and histologic specimen of the patients who underwent transoral robotic tongue base reduction surgery were retrospectively reviewed. Findings in computed tomography (CT) images, histopathological features of the removed tongue base tissues, and respiratory parameters in polysomnography were compared and analyzed. RESULTS Surgical specimens and CT images were available from 13 patients (aged 29-61 years). Histologic examination showed that the removed tissues comprised four layers-epithelial, lymphoid follicular, glandular, and muscle tissue. The median (interquartile range) thickness of the epithelial, lymphoid, and glandular layers was 0.29 (0.24-0.44) mm, 3.37 (1.67-4.75) mm, and 3.75 (3.45-4.10) mm, respectively. The lymphoid layer thickness on CT was correlated with that in the histologic section (r=0.967, p<0.001). However, the thickness of each layer had no significant correlation with the polysomnographic parameters. CONCLUSION The tongue base tissue removed by transoral robotic surgery in OSA patients comprised four distinctive layers including epithelial, lymphoid follicular, glandular and muscular layers. These layered structures could also be discriminated in the CT images.
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96
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Marques M, Genta PR, Azarbarzin A, Sands SA, Taranto-Montemurro L, Messineo L, White DP, Wellman A. Retropalatal and retroglossal airway compliance in patients with obstructive sleep apnea. Respir Physiol Neurobiol 2018; 258:98-103. [PMID: 29913264 DOI: 10.1016/j.resp.2018.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/09/2018] [Accepted: 06/15/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We hypothesized that preferential retropalatal as compared to retroglossal collapse in patients with obstructive sleep apnea was due to a narrower retropalatal area and a higher retropalatal compliance. Patients with a greater retropalatal compliance would exhibit a recognizable increase in negative effort dependence (NED). METHODS Fourteen patients underwent upper airway endoscopy with simultaneous recordings of airflow and pharyngeal pressure during natural sleep. Airway areas were obtained by manually outlining the lumen. Compliance was calculated by the change of airway area from end-expiration to a pressure swing of -5 cm H2O. NED was quantified for each breath as [peak inspiratory flow minus flow at -5 cm H2O]/[peak flow] × 100. RESULTS Compared to the retroglossal airway, the retropalatal airway was smaller at end-expiration (p < 0.001), and had greater absolute and relative compliances (p < 0.001). NED was positively associated with retropalatal relative area change (r = 0.47; p < 0.001). CONCLUSIONS Retropalatal airway is narrower and more collapsible than retroglossal airway. Retropalatal compliance is reflected in the clinically-available NED value.
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Affiliation(s)
- Melania Marques
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Laboratorio do Sono, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| | - Pedro R Genta
- Laboratorio do Sono, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Respiratory Medicine and Sleep Laboratory, Department of Experimental and Clinical Sciences, University of Brescia and Spedali Civili, Brescia, Italy
| | - David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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97
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Jain S, Kallio PJ, Less K, Novalija J, Pagel PS, Ebert TJ. Anesthesia Preoperative Clinic Evaluation of Obstructive Sleep Apnea Using Nasal Fiberoptic Videoendoscopy: A Pilot Study Comparison with Polysomnography. Anesth Pain Med 2018; 8:e63546. [PMID: 29868460 PMCID: PMC5970289 DOI: 10.5812/aapm.63546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 02/01/2018] [Indexed: 11/16/2022] Open
Abstract
Background Nasal fiberoptic videoendoscopy is an established technique to assess upper airway pathology in conscious and sedated patients. Objectives The authors conducted a prospective proof-of-concept pilot study to evaluate whether airway narrowing detected using nasal fiberoptic videoendoscopy in the anesthesia preoperative clinic was capable of defining the severity of obstructive sleep apnea (OSA) in patients scheduled for elective surgery. Methods After application of topical local anesthesia (4% lidocaine with phenylephrine), sixteen patients (ASA physical status 2 or 3) underwent nasal fiberoptic videoendoscopy in sitting position. The magnitudes of retropalatal and retrolingual luminal narrowing were assessed as predictors of OSA. Patients also underwent polysomnography and completed STOP-Bang questionnaires. The endoscopist's clinical impression of OSA severity based on the history and airway examination was quantified. Results Retropalatal luminal narrowing and STOP-Bang score ≥ 4 predicted OSA severity as either "none or mild" or "moderate to severe" in 13 (81%) and 9 (56%) of 16 patients who underwent polysomnography, respectively. OSA severity was significantly (Spearman's rank correlation coefficient) associated with retropalatal airway narrowing (P = 0.0048), STOP-BANG score (P = 0.0072), and body mass index (P = 0.0091), whereas clinical impression and retrolingual pharyngeal narrowing were not (P=0.093 and P = 0.11, respectively). Conclusions The current results suggest that nasal fiberoptic videoendoscopy quantification of retropalatal airway narrowing may be a useful tool for assessing the severity of OSA in the anesthesia preoperative clinic. The current findings document a proof-of-concept feasibility of nasal fiberoptic videoendoscopy as a screening tool for OSA in conscious patients during preoperative evaluation that may justify further prospective clinical trials of this technique.
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Affiliation(s)
- Sandeep Jain
- Anesthesia Service, Clement J. Zablocki Veterans Affair Medical Center, Milwaukee, Wisconsin, USA
| | - Peter J Kallio
- Anesthesia Service, Clement J. Zablocki Veterans Affair Medical Center, Milwaukee, Wisconsin, USA
| | - Kenneth Less
- Anesthesia Service, Clement J. Zablocki Veterans Affair Medical Center, Milwaukee, Wisconsin, USA
| | - Jutta Novalija
- Anesthesia Service, Clement J. Zablocki Veterans Affair Medical Center, Milwaukee, Wisconsin, USA
| | - Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affair Medical Center, Milwaukee, Wisconsin, USA
| | - Thomas J Ebert
- Anesthesia Service, Clement J. Zablocki Veterans Affair Medical Center, Milwaukee, Wisconsin, USA
- Corresponding author: Thomas J Ebert, MD PhD, Clement J. Zablocki Veterans Affairs Medical Center, Anesthesia Service, 5000 W. National Ave, Milwaukee, Wisconsin, USA. Tel: +1-4143842000-42417, Fax: +1-414902-5479, E-mail:
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98
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Veer V, Zhang H, Beyers J, Vanderveken O, Kotecha B. The use of drug-induced sleep endoscopy in England and Belgium. Eur Arch Otorhinolaryngol 2018; 275:1335-1342. [PMID: 29556753 PMCID: PMC5893728 DOI: 10.1007/s00405-018-4939-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/14/2018] [Indexed: 11/25/2022]
Abstract
Purpose The purpose of this international survey is to ascertain the current practice of drug-induced sleep endoscopy (DISE) for patients with sleep-disordered breathing (SDB) by Otolaryngologists in the United Kingdom and Belgium. We compare the results with recommendations from the European Position Paper on drug-induced sleep endoscopy. Methods An online questionnaire was circulated to Consultant Otolaryngologists, independent practitioners, and trainees across the two countries. Eleven questions were used in total. Results 181 responses from the UK and 117 responses from Belgium were received, mostly from consultants and independent practitioners. SDB was a common presentation to ENT practice, seen by over 90% of clinicians. The use of DISE varied greatly between the two countries (72.9% Belgium, 26.1% UK). 54.1% of Belgian respondents use DISE on over 50% of their patients, compared to only 32.4% of British clinicians. Attitudes of surgeons towards the diagnostic value of DISE varied; in Belgium, the majority (54%) gave a rating of 3 or more (1 = useless to 5 = essential), with no respondents giving a score of 0 (useless). In the UK only 16% of respondents felt DISE had useful clinical value, with 25 respondents deeming it ’useless’. The majority opt for DISE when non-surgical therapies fail (51.4% UK, 61.3% Belgium). The majority of participants do not use objective measures for depth of sedation (75.7% UK, 66.7% Belgium), with a marked variation on anaesthetic methods. 62.2% of UK clinicians do not use a classification system, whereas in Belgium the majority of clinicians (60.8%) use the VOTE grading system. Conclusions Clinicians in Belgium were more favourable to using DISE than in the UK. Differences in its clinical effectiveness were apparent between the two countries. A consensus on patient selection, method of sedation and an effective classification system seemed to be lacking from both countries. Further education is required to raise awareness for the use of DISE.
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Affiliation(s)
- Vik Veer
- Royal National Throat Nose and Ear Hospital, 330 Gray's Inn Rd, London, WC1X 8DA, UK
| | - Henry Zhang
- Queens Hospital, Rom Valley Way, Romford, RM7 0AG, UK
| | - Jolien Beyers
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, and, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Olivier Vanderveken
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, and, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Bhik Kotecha
- Royal National Throat Nose and Ear Hospital, 330 Gray's Inn Rd, London, WC1X 8DA, UK.
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99
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Towards a prediction model for drug-induced sleep endoscopy as selection tool for oral appliance treatment and positional therapy in obstructive sleep apnea. Sleep Breath 2018. [DOI: 10.1007/s11325-018-1649-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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100
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Azarbarzin A, Sands SA, Marques M, Genta PR, Taranto-Montemurro L, Messineo L, White DP, Wellman A. Palatal prolapse as a signature of expiratory flow limitation and inspiratory palatal collapse in patients with obstructive sleep apnoea. Eur Respir J 2018; 51:13993003.01419-2017. [PMID: 29444914 DOI: 10.1183/13993003.01419-2017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/29/2017] [Indexed: 12/20/2022]
Abstract
In some individuals with obstructive sleep apnoea (OSA), the palate prolapses into the velopharynx during expiration, limiting airflow through the nose or shunting it out of the mouth. We hypothesised that this phenomenon causes expiratory flow limitation (EFL) and is associated with inspiratory "isolated" palatal collapse. We also wanted to provide a robust noninvasive means to identify this mechanism of obstruction.Using natural sleep endoscopy, 1211 breaths from 22 OSA patients were scored as having or not having palatal prolapse. The patient-level site of collapse (tongue-related, isolated palate, pharyngeal lateral walls and epiglottis) was also characterised. EFL was quantified using expiratory resistance at maximal epiglottic pressure. A noninvasive EFL index (EFLI) was developed to detect the presence of palatal prolapse and EFL using the flow signal alone. In addition, the validity of using nasal pressure was assessed.A cut-off value of EFLI >0.8 detected the presence of palatal prolapse and EFL with an accuracy of >95% and 82%, respectively. The proportion of breaths with palatal prolapse predicted isolated inspiratory palatal collapse with 90% accuracy.This study demonstrates that expiratory palatal prolapse can be quantified noninvasively, is associated with EFL and predicts the presence of inspiratory isolated palatal collapse.
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Affiliation(s)
- Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Dept of Allergy Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Australia
| | - Melania Marques
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Sleep Laboratory, Pulmonary Division, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Pedro R Genta
- Sleep Laboratory, Pulmonary Division, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David P White
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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